A critical review of the diagnosis and management of Barrett's esophagus: the AGA Chicago Workshop

BACKGROUND & AIMS: The diagnosis and management of Barrett's esophagus (BE) are controversial. We conducted a critical review of the literature in BE to provide guidance on clinically relevant issues. METHODS: A multidisciplinary group of 18 participants evaluated the strength and the grade of evidence for 42 statements pertaining to the diagnosis, screening, surveillance, and treatment of BE. Each member anonymously voted to accept or reject statements based on the strength of evidence and his own expert opinion. RESULTS: There was strong consensus on most statements for acceptance or rejection. Members rejected statements that screening for BE has been shown to improve mortality from adenocarcinoma or to be cost-effective. Contrary to published clinical guidelines, they did not feel that screening should be recommended for adults over age 50, regardless of age or duration of heartburn. Members were divided on whether surveillance prolongs survival, although the majority agreed that it detects curable neoplasia and can be cost-effective in selected patients. The majority did not feel that acid-reduction therapy reduces the risk of esophageal adenocarcinoma but did agree that nonsteroidal antiinflammatory drugs are associated with a cancer risk reduction and are of promising (but unproven) value. Participants rejected the notion that mucosal ablation with acid suppression prevents adenocarcinoma in BE but agreed that this may be an appropriate strategy in a subgroup of patients with high-grade dysplasia. CONCLUSIONS: Based on this review of BE, the opinions of workshop members on issues pertaining to screening and surveillance are at variance with published clinical guidelines.     

Practical aspects of telehealth: doctor–patient relationship and communication

The fourth in a series of articles about the practical aspects of telehealth, this paper provides advice and information for specialists to communicate effectively with patients during a telehealth video consultation.     

Plasma Renin Activity and Its Association With Ischemic Heart Disease,Congestive Heart Failure,and Cerebrovascular Disease in a Large Hypertensive Cohort

Plasma renin activity (PRA) may be a surrogate for vascular damage. The authors hypothesize that PRA is associated with cardiovascular and cerebrovascular disease (CED). A cross‐sectional study (January 1, 1998, to December 31, 2009) was performed on hypertensive individuals 18 years and older using multivariable logistic regression models to estimate odds ratios (ORs) for ischemic heart disease (IHD), congestive heart failure (CHF), and CED based on PRA quartiles controlling for age, sex, race, diabetes mellitus (DM), and medication use. Among 7887 individuals (60% women; 34% whites, 23% blacks, and 19% Hispanics; and 29% with DM), the adjusted ORs (95% CI) for IHD were 0.94 (0.80–1.10), 1.09 (0.92–1.29), and 1.18 (1.00–1.39); for CHF were 1.23 (0.99–1.53), 1.27 (1.01–1.61), and 1.41 (1.13–1.77); and for CED were 0.95 (0.78–1.17), 0.77 (0.61–0.97), and 0.97 (0.78–1.20) for the second, third, and fourth quartiles compared with the first quartile. Higher PRA was associated with greater likelihood for prevalent IHD and CHF but not CED in this large ethnically diverse population of hypertensive individuals.     

ST-segment elevation and ventricular tachycardia after ingestion of a common ornamental plant-a case report

Japanese yew is a widely used ornamental plant. However, most people are unaware that it is also a poisonous plant. It has potent cardiac toxicities that can lead to sudden cardiac death. A 37-year-old female patient presented to the emergency room with altered mental status and sustained ventricular tachycardia (VT). Electrocardiogram (ECG) after cardioversion showed profound QRS prolongation and ST-segment elevation suggestive of either hyperkalaemia, acute myocardial ischaemia, or Brugada syndrome. Her electrolytes and coronary angiography were normal. After improvement of the patient's mental status, she admitted that she has been consuming Japanese yew from her yard for several months. Few hours later, QRS duration normalised, but mild ST-segment elevation persisted in the right pre-cordial leads, making it more suspicious for Brugada syndrome. However, a procainamide challenge test and electrophysiology study failed to induce typical Brugada pattern ECG and VT. The absence of coronary artery disease and electrolytes disturbances points toward the fact that her arrhythmia and ECG changes are secondary to yew intoxication. The patient was monitored for a few days. She was haemodynamically stable and has not had any arrhythmia. This case highlights the importance of public awareness of severe toxicity from Japanese yew or other yew plants. Yews contain taxines that are responsible for the ECG abnormalities due to its inhibitory effect on the cardiac sodium and calcium channels. They cause conduction abnormalities, VT, and ST-segment elevation that can resemble acute myocardial infarction, hyperkalaemia, and Brugada syndrome.